- Email: [email protected]
Obstetrics
mia. Urinary tract infections are responsible for up to 40% of nosocomial infections.
other hand, silver alloy catheters have been shown by the authors to have a protective benefit.
Question 11: The leading cause of nosocomial bacteremia infection is associated with which of the following? Answer: c) Intravascular catheters. Bacteremia complicates up to 4% of nosocomial urinary tract infections, and more than 17% of nosocomial bacteremia cases are attributable to the urinary tract. Only intravascular catheters have caused a greater number of nosocomial bacteremia cases.
. . .
Question 12: Which of the following is NOT a significant risk for developing bacteremia in a patient with an indwelling urinary catheter? Answer: d) Suprapubic rather than urethral catheter. This is the correct answer based on bacteremia. However, the question actually read that the patient had an indwelling urinary catheter so credit was given to everyone. Actual risk f&tors tbr bacteremia include being female, prolonged use, older age, diabetes, and others. A suprapubic catheter is associated with a lower risk and higher rate of sati&ction. Question 13: Most experts do not recommend routinely using prophylactic antibiotic medications for patients with long-term indwelling urinary catheters for each of the following reasons EXCEPT Answer: d) Not ef&ctive. Several studies have shown that prophylaxis increases resistant organisms. Others have reported concerns of cost and adverse effect potential although there is evidence that antibiotic medications do decrease bacteremia, especially in short-term catheterization. Question 14: Which of the following is the BEST method to reduce the incidence of bacteremia in adults at high risk for complications of catheterassociated bacteremia? Answer: a) Silver alloy catheter. A number of interventions have been studied in an effort to reduce catheterrelated urinary tract infections and potential bacteremia. Of these, antibacterial bladder irrigation, antibiotics in the drainage bag, and rigorous cleaning have been shown to have either no effect or mixed results. Silver oxide catheters are not significantly better than ordinary catheters. On the 02001 by the American College of Obstetricians and Gynecologists PublIshed by Elsevier Science Inc. 106.56862/01/$6.00
SmetanaGW. PrcoPerativepuhnonaryevaluation.N JJnglJ Mal1999;340:937-44. Synopsis: The author reviewed current concepts in preoperative pulmonary evaluation. Discussion concen-
trated on risk factors, both patient and procedure related. He also explained the clinical evaluation and risk-reduction strategies.
the most critical determinant of pulmonary risk. The upper abdomen and chest carry the greatest risk, ranging from 10% to 40%. Question19: Which of the following is the LEAST important symptom in the preoperative history and physical exam related to postoperative pulmonary complications? Answer: c) Nasal allergies. A history of exercise intolerance, chronic cough, or unexplained dyspnea is associated with a greater risk of pulmonary postoperative complications.
Question 15 In recent studies, the definition of postoperative pulmonary complications has included complications which produce each of the following EXCEPT Answer: d) Productive cough. Although early definitions included items such as a productive cough, elevated temperature, or new physical signs, these have been shown to have little clinical significance. Recent studies include only complications that prolong hospital stays, contribute to morbidity and mortality, and result in prolonged mechanical ventilation. Examples include pneumonia, respiratory failure, bronchospasm, and atelectasis.
20: Which of the following is the mainstay of risk reduction strategies for postoperative pulmonary complications? Answer: a) Postoperative lung expansion maneuvers. Since obesity has
Question 16: The author recommends that smoking cessation should be encouraged for a minimum of how many weeks prior to elective surgery? Answer: b) 8 weeks. Smoking is a risk factor for postoperative complications. The relative risk compared with nonsmokers ranges from 1.4 to 43. It takes about 8 weeks of nonsmoking for the risk to decline.
American C&ge
Question 17: Which of the following is the LJZAST significant risk factor for postoperative pulmonary complications? Answer: c) Obesity. In two studies of patients with obesity undergoing surgery, there was no significant di&rence in the risk of pulmonary complications between obese and nonobese patients. Smokers, asthmatics, and patients with chronic obstructive disease all had greater risks. 18: Which of the following operative incisions is associated with the GREATEST risk for postopera-
Question
tive pulmonary complications? Answer: d) Upper abdominal midline incision. The surgical site is
Question
been found to make no significant d& ference in postoperative complications, weight loss does not reduce the risk of the complications. Preoperative antibiotics are helpful if a respiratory infection is present. Risk reduction by use of intercostal nerve blocks did not reach a significant level.
OBSTETUICS of Obstetriciansand Gy-
necologists. Thrombocytopenia in pregnancy. ACOG Practice Bulletin No. 6. Washington,DC: ACOG, 1999.
Synop& Thrombocytopenia results when the platelet count drops below 15O,OOO/~L. It occurs in 7-8% of pregnancies. There are multiple etiologies but the diagnosis should be as precise as possible to ensure the most appropriate care. This bulletin outlines specific recommendations. Qdon 21: Which of the following is the LEAST common manifestation of thrombocytopenia in a nonpregnant woman? Answer: b) Intracranial hemorrhage. Thrombocytopenia, unlike other bleeding disorders, usually results in bleeding in the mucous membranes. Manifestations include petechiae, ecchymoses, epistaxis, gingival bleeding, and menometrorrhagia. Bleeding in joints or hollow cavities is rare. Question 22: Clinically significant bleeding, not associated with surgery or trauma, usually is limited to preg-
March/April 2001
l
ACOG CLINICAL REVIEW
l
3
nant women with platelet counts less than Answer: a) lO,OOO/pL. The normal platelet count is usually reported as 150,000-4OO,OOO/pL. The mean platelet count in pregnant women is usually lower. Clinically significant bleeding usually does not occur in the absence of trauma until the total count drops below lO,OOO/pL. Question 23: Findings traditionally associated with immune thrombocytopenic p~ura (HP) include each of the following EXCEPT Answer: c) Slower than normal rate of platelet destruction by the spleen. Immune thrombocytopenic purpura has no pathognomonic signs or symptoms and no specific diagnostic tests. It is diagnosed by excluding other causes and traditionally has four findings: persistent low platelet count, absent splenomegaly, normal or increased numbers of megakaryocytes, and exclusion of other disorders. Question 24: Pregnancy-induced hypertension is the cause of approximately what percent of cases of maternal thrombocytopenia? Answer: b) 20%. Pregnancyinduced hypertension (PIH) is associated with approximately 2 1% of cases
of maternal thrombocytopenia. etiologic factor is unknown.
The
Qnestion 25: Which of the following diseases is NOT usually considered in the drench diagnosis of thrombocytopenia in pregnancy? Answer: d) Infectious mononucleosis. At least 14 etiologic factors have been found that can result in thrombocytopenia in pregnancy. Among these are PIH, HIV infection, systemic lupus erythematosus, medications, as well as other causes. Infectious mononucleosis has not been implicated. Question 26: The first line of treatment of ITP during pregnancy is Answer: c) Prednisone. The first line of treatment for ITP is prednisone, usually l-2mg/kg/day. Other treatments that can be used if there is no response to prednisone are intravenous immune goblin, splenectomy, and, for life-threatening situations, platelet transfusions. Question 27: Epidural anesthesia is usually considered safe in pregnant
4
l
ACOG CLINICAL REVIEW
l
women with platelet counts
greater
than Answer: d) lOO,OOO/~L. The data, although limited, support the safety of regional anesthesia when a patient has a platelet count of lOO,OOOl~L or more. Counts of less than ~O,OOO/~ contradict use of epidural agents, whereas counts between 50,000 and 99,0OOl/.~L may or may not be safe for epidural agent use and require a careful review and consensus of the medical team. l
.
l
AmericanAcademyof Pediatrics,Task Force on Ciicurncision. Circumcision policy statement. Pediatrics 1999;103:686-93. Question
28: The MOST f%equent
complication associated with neonatal circumcision is Answer: b) Bleeding. Bleeding is seen in about 0.1% of circumcisions. It is rare that it occurs to the extent that transfusion is needed. Infection is the second most common complication but is usually minor. Other instances of complications are rare. Qnortion
29: The MOST effective
analgesia for neonatal circumcision is which of the following? Answer: c) Subcutaneous ring block. Use of analgesia is now recommended as studies have shown that circumcision without analgesia results in pain and physiologic stress. Eutectic mixture of local anesthetic agents in a cream, dorsal penile nerve block, subcutanwus ring block, and even sucrose on a pacifier have been studied. The ring block provides the most effective analgesia. Question 30: The relative risk of urinary tract infection during the first year of life in uncircumcised male infants compared with circumcised male infants is increased Answer: b) Four- to ten-fold. Multiple studies have shown that the uncircumcised male infant is at greater risk for developing a urinary
tract infection in the first year of life than a circumcised male infant. Although each study varies in its methodology, a summary of all studies indicates this risk to be four to ten times higher. Qdon 31:Which of the following anogenital cancers has the lowest prevalence of being associated with HPV DNA?
March/ApriI 2001
Answer: d) Penile. Although the relationship of human papi~oma~~ and genital cancer has been established, this relationship is much more common for cancers of the anus, vagina, vulva, and cervix than it is for the penis.
*
l
.
Haddow JE, Palomaki GE, AUanWC, et al. Maternal thyroid deficiency during prcgnancy and subsequent neuropsychological development of the chid. N Eagl J Mtd X99%342:549-55.
Utiger RD. Maternal ~~~~oi~rn fetal dnrelopment [&o&I]. 1999;341:601-2.
and N Engi J Mad
Synopsis:
These authors studied stored serum samples of pregnant women to determine thyrotropin levels. For those women with high ievels,
they proceeded to evaluate the IQ scores of their children and compared the results with matched controls. They concluded that undiagnosed hypothyroidism in pregnancy may adversely affect the infant. ACOG Technical Bdhin No. 181, June 1993, entitled Thyroid Disease in Pregnancy, contains an excellent summary of the problem of both hyper- and hypothyroidism and pregnancy, but does not~~~on~e~t. Question 32: The MOST common cause of hypothyroidism in women during childbearing years in the United States is Answer: a) Chronic autoimmune thyroiditis. The link between iodine deficiency and hypothyroidism has been established for years. However, in developed countries where iodine supplementation is ever-present, it is less of a problem than autoimmune causes. Q~tion 33: Because the symptoms associated with hypothyroidism are nonspecific, the median time (years) to diagnosis in women is Answer: c) 5 years. As shown in this study the symptoms of hypothyroidism are nonspecific, therefore, making the diagnosis is difficult. Question 34: Maternal hypothyroidism is LEAST frequently associated
with which of the f&wing conditions? Answer: d) Permanent congenital hypothyroidism. In the accompanying editorial, Dr. Utiger notes that fertility is decreased with hypothyroidism and that those who became @ZOO1 by the~e~~fl
College ofObst~~~~nsa~dG~ecolosisfs hibiiihed by Eisevter Science inc. 1085~6WAl146.00
pregnant had a higher incidence of preterm delivery and preeclampsia. The infants are also small for gestational age. Question 35: The relative need for maternal thyroxin throughout pregnancy Answer: a) Increases. Thyroid secretion increases in pregnancy in large part due to the need to provide thyroid hormone for the fetus and because of the increased needs of the mother. . . . Norwin ER, Robinson JN, Challis JRG. The control of labor. N Engl J Med 1999; 341660-6.
Question 36: The final common pathway for labor in almost all species appears to be activation of Answer: b) Fetal hypothalamicpituitary-adrenal axis. Once the myometrium and cervix are prepared for labor, the fetal placental unit changes the pattern of myometrial activity to regular contractions. This change may be coordinated by fetal influence on the production of placental steroid hormones, distention of the uterus, and secretion of neurohypophysial hormones and other stimulators. Question 37: Which of the following factors is NOT included in thii article as a risk factor for preterm labor? Answer: d) High maternal weight before pregnancy. Risk factors for preterm labor include a history of preterm delivery, multiple gestations, uterine anomalies, hydramnios, infection, younger or older age, low weight before pregnancy, low socioeconomic status, and smoking. Question 38: Currently, selection of the MOST appropriate tocolytic drug for a given woman is based primarily on which of the following? Answer: a) Side effects. Drug therapy is the mainstay of preterm labor management. Although many agents are available, apparently none delay labor beyond 48 hours; thus, the major consideration should be the side effects the patient will likely experience. Qnestion 39: The authors state that none of the presently available tocolytic agents delay delivery for more than how many hours? Answer: b) 48 hours. As noted in question 38, no single medication has 02001 by the Amencan College 01 Obstetrw%ms and Gynecologists Published by Elsevw Science Inc 1085-6862/01/$6.00
been shown to consistently delay the onset of labor beyond 48 hours. Qaaation 40: In the United States, the fim-line drug used to treat preterm labor is Answer: d) Magnesium sulfate. A number of drugs have been tried in an attempt to suppress preterm labor. The first was ethanol, followed by P-adrenergic agonists, prostaglandin inhibitors, calcium channel blockers, oxytocin-receptor antagonists, and so on. However, magnesium sulfate, which suppresses the activation of the myosin-actin contractile unit, is still considered the first line of treatment by these authors. ACOG Technical Bdktin No. 206 June 1995, entitled Preterm Labor, indicates that ritodrine and magnesium sulfate are similar in efftcacy and side effects.
OFFICE PRACTICE AmericanCdlegeof Obstetricians and Gynecologists. Prophylactic oophorectomy. ACOG Practice Bulletin No. 7. Washington, DC: ACOG, 1999.
Synopsis: Prophylactic oophorectomy has been advocated historically at the time of hysterectomy to prevent future cancer or other ovary-related symptoms. The opposing arguments center around the continued benefits of ovarian hormone production. This Practice Bulletin reviews the background and clinical considerations and provides recommendations. Question 41: The Centers for Disease Control and Prevention collected data between 1988 and 1993 concerning hysterectomy in women who were 40 years of age or older. One or both ovaries were NOT removed in approximately what percent of these women? Answer: c) 40-50%. In the United States, there are approximately 600,000 hysterectomies each year. Between 1988 and 1993, ovarian retention in women over age 40 undergoing hysterectomy was approximately 4O-50%. It has been estimated that 1000 cases of ovarian cancer would be prevented if all women over 40 who undergo hysterectomy also undergo prophylactic oophorectomy. The question is whether preventing these additional cases justifies the consequences of estrogen loss in the other women.
won 42: Chronic oral contraceptive use confers little additional protection against the development of invasive epithelial ovarian cancer after how many years of use? Answer: b) 6 years. Prior use of oral contraceptives decmases theriskof ovarian epithelial cancer. This risk continues to decrease until 6 years of oral contraceptive use. Beyond this time, there is no additional reduction in risk Question 43: The stroma of the postmenopausal ovary produces which of the following hormones? Answer: a) Androgens. Ovarian follicles produce both androgens and estrogens, whereas ovarian stromal tissue produces androgens. The role of removal of this source of androgens has not been fully determined. Question 44: The approximate percentage of all ovarian cancers related to inherited mutations in the BRGX-1 gene is Answer: c) 5%. The role of BRCXI mutations in ovarian cancer has been studied extensively. Recent studies indicate that the mutation occurs in approximately 5% of women who have ovarian cancer diagnosed prior to age 70. BRCX’ mutations also increase the risk but to a lesser degree than BRCAI mutations. Question 45: The reoperation rate for ovarian pathology in women who have at least one ovary remaining after undergoing hysterectomy for benign indications is approximately what percent? Answer: b) 4%. The major indication for reoperation following removal of the ovaries is cited as pain. When one ovary is retained, there is approximately a 4% chance of reoperation. . . . Manson JE, Hu FB, Rich-EdwardsJW, et al. A prospective study of walking as compared with vigorous cx&se in the prevention of coronary heart disease in women. N I!4 J Med 1999$41:650-K Synopsk
This prospective study indicates that brisk walking and vigorous exercise are associated with similar reductions in the incidence of coronary events in women.
Question 46: In this study, more physically active women were currently more likely to use each of the following EXCEPT
March/April 2001
l
ACOG CLINICAL
REVIEW
l
5
other hand, silver alloy catheters have been shown by the authors to have a protective benefit.
Question 11: The leading cause of nosocomial bacteremia infection is associated with which of the following? Answer: c) Intravascular catheters. Bacteremia complicates up to 4% of nosocomial urinary tract infections, and more than 17% of nosocomial bacteremia cases are attributable to the urinary tract. Only intravascular catheters have caused a greater number of nosocomial bacteremia cases.
. . .
Question 12: Which of the following is NOT a significant risk for developing bacteremia in a patient with an indwelling urinary catheter? Answer: d) Suprapubic rather than urethral catheter. This is the correct answer based on bacteremia. However, the question actually read that the patient had an indwelling urinary catheter so credit was given to everyone. Actual risk f&tors tbr bacteremia include being female, prolonged use, older age, diabetes, and others. A suprapubic catheter is associated with a lower risk and higher rate of sati&ction. Question 13: Most experts do not recommend routinely using prophylactic antibiotic medications for patients with long-term indwelling urinary catheters for each of the following reasons EXCEPT Answer: d) Not ef&ctive. Several studies have shown that prophylaxis increases resistant organisms. Others have reported concerns of cost and adverse effect potential although there is evidence that antibiotic medications do decrease bacteremia, especially in short-term catheterization. Question 14: Which of the following is the BEST method to reduce the incidence of bacteremia in adults at high risk for complications of catheterassociated bacteremia? Answer: a) Silver alloy catheter. A number of interventions have been studied in an effort to reduce catheterrelated urinary tract infections and potential bacteremia. Of these, antibacterial bladder irrigation, antibiotics in the drainage bag, and rigorous cleaning have been shown to have either no effect or mixed results. Silver oxide catheters are not significantly better than ordinary catheters. On the 02001 by the American College of Obstetricians and Gynecologists PublIshed by Elsevier Science Inc. 106.56862/01/$6.00
SmetanaGW. PrcoPerativepuhnonaryevaluation.N JJnglJ Mal1999;340:937-44. Synopsis: The author reviewed current concepts in preoperative pulmonary evaluation. Discussion concen-
trated on risk factors, both patient and procedure related. He also explained the clinical evaluation and risk-reduction strategies.
the most critical determinant of pulmonary risk. The upper abdomen and chest carry the greatest risk, ranging from 10% to 40%. Question19: Which of the following is the LEAST important symptom in the preoperative history and physical exam related to postoperative pulmonary complications? Answer: c) Nasal allergies. A history of exercise intolerance, chronic cough, or unexplained dyspnea is associated with a greater risk of pulmonary postoperative complications.
Question 15 In recent studies, the definition of postoperative pulmonary complications has included complications which produce each of the following EXCEPT Answer: d) Productive cough. Although early definitions included items such as a productive cough, elevated temperature, or new physical signs, these have been shown to have little clinical significance. Recent studies include only complications that prolong hospital stays, contribute to morbidity and mortality, and result in prolonged mechanical ventilation. Examples include pneumonia, respiratory failure, bronchospasm, and atelectasis.
20: Which of the following is the mainstay of risk reduction strategies for postoperative pulmonary complications? Answer: a) Postoperative lung expansion maneuvers. Since obesity has
Question 16: The author recommends that smoking cessation should be encouraged for a minimum of how many weeks prior to elective surgery? Answer: b) 8 weeks. Smoking is a risk factor for postoperative complications. The relative risk compared with nonsmokers ranges from 1.4 to 43. It takes about 8 weeks of nonsmoking for the risk to decline.
American C&ge
Question 17: Which of the following is the LJZAST significant risk factor for postoperative pulmonary complications? Answer: c) Obesity. In two studies of patients with obesity undergoing surgery, there was no significant di&rence in the risk of pulmonary complications between obese and nonobese patients. Smokers, asthmatics, and patients with chronic obstructive disease all had greater risks. 18: Which of the following operative incisions is associated with the GREATEST risk for postopera-
Question
tive pulmonary complications? Answer: d) Upper abdominal midline incision. The surgical site is
Question
been found to make no significant d& ference in postoperative complications, weight loss does not reduce the risk of the complications. Preoperative antibiotics are helpful if a respiratory infection is present. Risk reduction by use of intercostal nerve blocks did not reach a significant level.
OBSTETUICS of Obstetriciansand Gy-
necologists. Thrombocytopenia in pregnancy. ACOG Practice Bulletin No. 6. Washington,DC: ACOG, 1999.
Synop& Thrombocytopenia results when the platelet count drops below 15O,OOO/~L. It occurs in 7-8% of pregnancies. There are multiple etiologies but the diagnosis should be as precise as possible to ensure the most appropriate care. This bulletin outlines specific recommendations. Qdon 21: Which of the following is the LEAST common manifestation of thrombocytopenia in a nonpregnant woman? Answer: b) Intracranial hemorrhage. Thrombocytopenia, unlike other bleeding disorders, usually results in bleeding in the mucous membranes. Manifestations include petechiae, ecchymoses, epistaxis, gingival bleeding, and menometrorrhagia. Bleeding in joints or hollow cavities is rare. Question 22: Clinically significant bleeding, not associated with surgery or trauma, usually is limited to preg-
March/April 2001
l
ACOG CLINICAL REVIEW
l
3
nant women with platelet counts less than Answer: a) lO,OOO/pL. The normal platelet count is usually reported as 150,000-4OO,OOO/pL. The mean platelet count in pregnant women is usually lower. Clinically significant bleeding usually does not occur in the absence of trauma until the total count drops below lO,OOO/pL. Question 23: Findings traditionally associated with immune thrombocytopenic p~ura (HP) include each of the following EXCEPT Answer: c) Slower than normal rate of platelet destruction by the spleen. Immune thrombocytopenic purpura has no pathognomonic signs or symptoms and no specific diagnostic tests. It is diagnosed by excluding other causes and traditionally has four findings: persistent low platelet count, absent splenomegaly, normal or increased numbers of megakaryocytes, and exclusion of other disorders. Question 24: Pregnancy-induced hypertension is the cause of approximately what percent of cases of maternal thrombocytopenia? Answer: b) 20%. Pregnancyinduced hypertension (PIH) is associated with approximately 2 1% of cases
of maternal thrombocytopenia. etiologic factor is unknown.
The
Qnestion 25: Which of the following diseases is NOT usually considered in the drench diagnosis of thrombocytopenia in pregnancy? Answer: d) Infectious mononucleosis. At least 14 etiologic factors have been found that can result in thrombocytopenia in pregnancy. Among these are PIH, HIV infection, systemic lupus erythematosus, medications, as well as other causes. Infectious mononucleosis has not been implicated. Question 26: The first line of treatment of ITP during pregnancy is Answer: c) Prednisone. The first line of treatment for ITP is prednisone, usually l-2mg/kg/day. Other treatments that can be used if there is no response to prednisone are intravenous immune goblin, splenectomy, and, for life-threatening situations, platelet transfusions. Question 27: Epidural anesthesia is usually considered safe in pregnant
4
l
ACOG CLINICAL REVIEW
l
women with platelet counts
greater
than Answer: d) lOO,OOO/~L. The data, although limited, support the safety of regional anesthesia when a patient has a platelet count of lOO,OOOl~L or more. Counts of less than ~O,OOO/~ contradict use of epidural agents, whereas counts between 50,000 and 99,0OOl/.~L may or may not be safe for epidural agent use and require a careful review and consensus of the medical team. l
.
l
AmericanAcademyof Pediatrics,Task Force on Ciicurncision. Circumcision policy statement. Pediatrics 1999;103:686-93. Question
28: The MOST f%equent
complication associated with neonatal circumcision is Answer: b) Bleeding. Bleeding is seen in about 0.1% of circumcisions. It is rare that it occurs to the extent that transfusion is needed. Infection is the second most common complication but is usually minor. Other instances of complications are rare. Qnortion
29: The MOST effective
analgesia for neonatal circumcision is which of the following? Answer: c) Subcutaneous ring block. Use of analgesia is now recommended as studies have shown that circumcision without analgesia results in pain and physiologic stress. Eutectic mixture of local anesthetic agents in a cream, dorsal penile nerve block, subcutanwus ring block, and even sucrose on a pacifier have been studied. The ring block provides the most effective analgesia. Question 30: The relative risk of urinary tract infection during the first year of life in uncircumcised male infants compared with circumcised male infants is increased Answer: b) Four- to ten-fold. Multiple studies have shown that the uncircumcised male infant is at greater risk for developing a urinary
tract infection in the first year of life than a circumcised male infant. Although each study varies in its methodology, a summary of all studies indicates this risk to be four to ten times higher. Qdon 31:Which of the following anogenital cancers has the lowest prevalence of being associated with HPV DNA?
March/ApriI 2001
Answer: d) Penile. Although the relationship of human papi~oma~~ and genital cancer has been established, this relationship is much more common for cancers of the anus, vagina, vulva, and cervix than it is for the penis.
*
l
.
Haddow JE, Palomaki GE, AUanWC, et al. Maternal thyroid deficiency during prcgnancy and subsequent neuropsychological development of the chid. N Eagl J Mtd X99%342:549-55.
Utiger RD. Maternal ~~~~oi~rn fetal dnrelopment [&o&I]. 1999;341:601-2.
and N Engi J Mad
Synopsis:
These authors studied stored serum samples of pregnant women to determine thyrotropin levels. For those women with high ievels,
they proceeded to evaluate the IQ scores of their children and compared the results with matched controls. They concluded that undiagnosed hypothyroidism in pregnancy may adversely affect the infant. ACOG Technical Bdhin No. 181, June 1993, entitled Thyroid Disease in Pregnancy, contains an excellent summary of the problem of both hyper- and hypothyroidism and pregnancy, but does not~~~on~e~t. Question 32: The MOST common cause of hypothyroidism in women during childbearing years in the United States is Answer: a) Chronic autoimmune thyroiditis. The link between iodine deficiency and hypothyroidism has been established for years. However, in developed countries where iodine supplementation is ever-present, it is less of a problem than autoimmune causes. Q~tion 33: Because the symptoms associated with hypothyroidism are nonspecific, the median time (years) to diagnosis in women is Answer: c) 5 years. As shown in this study the symptoms of hypothyroidism are nonspecific, therefore, making the diagnosis is difficult. Question 34: Maternal hypothyroidism is LEAST frequently associated
with which of the f&wing conditions? Answer: d) Permanent congenital hypothyroidism. In the accompanying editorial, Dr. Utiger notes that fertility is decreased with hypothyroidism and that those who became @ZOO1 by the~e~~fl
College ofObst~~~~nsa~dG~ecolosisfs hibiiihed by Eisevter Science inc. 1085~6WAl146.00
pregnant had a higher incidence of preterm delivery and preeclampsia. The infants are also small for gestational age. Question 35: The relative need for maternal thyroxin throughout pregnancy Answer: a) Increases. Thyroid secretion increases in pregnancy in large part due to the need to provide thyroid hormone for the fetus and because of the increased needs of the mother. . . . Norwin ER, Robinson JN, Challis JRG. The control of labor. N Engl J Med 1999; 341660-6.
Question 36: The final common pathway for labor in almost all species appears to be activation of Answer: b) Fetal hypothalamicpituitary-adrenal axis. Once the myometrium and cervix are prepared for labor, the fetal placental unit changes the pattern of myometrial activity to regular contractions. This change may be coordinated by fetal influence on the production of placental steroid hormones, distention of the uterus, and secretion of neurohypophysial hormones and other stimulators. Question 37: Which of the following factors is NOT included in thii article as a risk factor for preterm labor? Answer: d) High maternal weight before pregnancy. Risk factors for preterm labor include a history of preterm delivery, multiple gestations, uterine anomalies, hydramnios, infection, younger or older age, low weight before pregnancy, low socioeconomic status, and smoking. Question 38: Currently, selection of the MOST appropriate tocolytic drug for a given woman is based primarily on which of the following? Answer: a) Side effects. Drug therapy is the mainstay of preterm labor management. Although many agents are available, apparently none delay labor beyond 48 hours; thus, the major consideration should be the side effects the patient will likely experience. Qnestion 39: The authors state that none of the presently available tocolytic agents delay delivery for more than how many hours? Answer: b) 48 hours. As noted in question 38, no single medication has 02001 by the Amencan College 01 Obstetrw%ms and Gynecologists Published by Elsevw Science Inc 1085-6862/01/$6.00
been shown to consistently delay the onset of labor beyond 48 hours. Qaaation 40: In the United States, the fim-line drug used to treat preterm labor is Answer: d) Magnesium sulfate. A number of drugs have been tried in an attempt to suppress preterm labor. The first was ethanol, followed by P-adrenergic agonists, prostaglandin inhibitors, calcium channel blockers, oxytocin-receptor antagonists, and so on. However, magnesium sulfate, which suppresses the activation of the myosin-actin contractile unit, is still considered the first line of treatment by these authors. ACOG Technical Bdktin No. 206 June 1995, entitled Preterm Labor, indicates that ritodrine and magnesium sulfate are similar in efftcacy and side effects.
OFFICE PRACTICE AmericanCdlegeof Obstetricians and Gynecologists. Prophylactic oophorectomy. ACOG Practice Bulletin No. 7. Washington, DC: ACOG, 1999.
Synopsis: Prophylactic oophorectomy has been advocated historically at the time of hysterectomy to prevent future cancer or other ovary-related symptoms. The opposing arguments center around the continued benefits of ovarian hormone production. This Practice Bulletin reviews the background and clinical considerations and provides recommendations. Question 41: The Centers for Disease Control and Prevention collected data between 1988 and 1993 concerning hysterectomy in women who were 40 years of age or older. One or both ovaries were NOT removed in approximately what percent of these women? Answer: c) 40-50%. In the United States, there are approximately 600,000 hysterectomies each year. Between 1988 and 1993, ovarian retention in women over age 40 undergoing hysterectomy was approximately 4O-50%. It has been estimated that 1000 cases of ovarian cancer would be prevented if all women over 40 who undergo hysterectomy also undergo prophylactic oophorectomy. The question is whether preventing these additional cases justifies the consequences of estrogen loss in the other women.
won 42: Chronic oral contraceptive use confers little additional protection against the development of invasive epithelial ovarian cancer after how many years of use? Answer: b) 6 years. Prior use of oral contraceptives decmases theriskof ovarian epithelial cancer. This risk continues to decrease until 6 years of oral contraceptive use. Beyond this time, there is no additional reduction in risk Question 43: The stroma of the postmenopausal ovary produces which of the following hormones? Answer: a) Androgens. Ovarian follicles produce both androgens and estrogens, whereas ovarian stromal tissue produces androgens. The role of removal of this source of androgens has not been fully determined. Question 44: The approximate percentage of all ovarian cancers related to inherited mutations in the BRGX-1 gene is Answer: c) 5%. The role of BRCXI mutations in ovarian cancer has been studied extensively. Recent studies indicate that the mutation occurs in approximately 5% of women who have ovarian cancer diagnosed prior to age 70. BRCX’ mutations also increase the risk but to a lesser degree than BRCAI mutations. Question 45: The reoperation rate for ovarian pathology in women who have at least one ovary remaining after undergoing hysterectomy for benign indications is approximately what percent? Answer: b) 4%. The major indication for reoperation following removal of the ovaries is cited as pain. When one ovary is retained, there is approximately a 4% chance of reoperation. . . . Manson JE, Hu FB, Rich-EdwardsJW, et al. A prospective study of walking as compared with vigorous cx&se in the prevention of coronary heart disease in women. N I!4 J Med 1999$41:650-K Synopsk
This prospective study indicates that brisk walking and vigorous exercise are associated with similar reductions in the incidence of coronary events in women.
Question 46: In this study, more physically active women were currently more likely to use each of the following EXCEPT
March/April 2001
l
ACOG CLINICAL
REVIEW
l
5